Allergic contact dermatitis induced by topical hydrocortisone butyrate propionate mimicking acute generalized exanthematous pustulosis

ARTICLE

Auteur(s) : Natsuko Tohgi, Hiromitsu Eto, Hideki Maejima, Norimitsu Saito, Mika Nakamura, Kensei Katsuoka

Department of Dermatology, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa, 228-8555, Japan

Herein, we report a rare case of allergic contact dermatitis induced by topical hydrocortisone 17-butyrate 21-propionate (HBP), which resembled acute generalized exanthematous pustulosis (AGEP).

A 31-year-old Japanese woman with atopic dermatitis was treated by topical application of Pandel^® ointment, containing HBP. Soon after the start of application of the ointment, she developed edematous erythema with pustules at the sites of application of the ointment, and was referred to our department because the eruptions spread rapidly within two days to involve large parts of the body, associated with high-grade fever. At the first examination, erythematous papules and irregular erythematous lesions with purpura were noted on the back and lower limbs (figure 1A). Numerous pustules were also observed on the neck, axilla and arms, however, there was no evidence of mucosal involvement. Laboratory studies revealed elevated white blood cell and neutrophil counts with a slight increase in the eosinophil count; serum tests for antistreptolysin O and viral antibodies (Epstein-Barr virus and cytomegalovirus) were negative. Bacterial and fungal cultures of blood, tonsillar swabs and material obtained from the pustules were negative.

Histopathological examination of the pustules showed that they arose in the subcorneal layer, with inflammatory cell infiltration of the dermis; there was no evidence of vasculitis (figure 1B). We discontinued the Pandel^® ointment, and started her on oral betamethasone. Two weeks later, the eruptions had completely disappeared.

Positive reactions were seen to Pandel^® ointment 0.1% pet. and HBP 0.01% pet. at 48 hr and 72hr, and 7days (figure 1C). In addition, patch tests conducted for hydrocortisone butyrate (HB) 0.1% pet. and prednisolone valerate acetate (PVA) 0.1% pet. also revealed positive reactions (figure 1D), whereas patch testing for other corticosteroids was negative.

HBP, HB and PVA, but not the other corticosteroids tested, have an ester substitution at the C17 position. Based on these results, we diagnosed the condition of the patient as pustule-forming allergic contact dermatitis induced by topical C17-substituted corticosteroid preparations.

Our patient showed an important difference from cases of systemic contact dermatitis caused by cobalt and nickel [1]. In our case, the histopathological examination revealed subcorneal pustules and the clinical manifestations included numerous pin-sized pustules and irregular erythematous lesions with purpura. These findings are rarely observed in systemic contact dermatitis. Assessment of our patient according to the Euro SCAR group criteria revealed a score of 8 [2], however, the patch test reaction was mildly positive. Based on these findings and previous descriptions of the condition [3], we diagnosed our patient as a case of AGEP-like allergic contact dermatitis [3]. AGEP is well known to be induced by oral antibiotics and mercury, but AGEP or AGEP-like eruptions have rarely been reported to be caused by topical corticosteroids [3, 4]. A large study revealed that 1% of patients show a positive patch test reaction to HB [5]. HB, HBP and PVA have an ester substitution at the C17 position, and this C17-ester has an allergogenic property, similar to C17-acetonide, such as in budesonide [6]. The mechanism of development of AGEP in our case remains unknown. However, systemic absorption of topically applied agents can cause AGEP or AGEP-like eruptions [2-4]. Our case was a rare one, but nonetheless, posed a serious problem.

Acknowledgements

References

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